This book sets echocardiography within a routine clinical context. It aims to synthesise guidelines into a pragmatic clinical approach to real patients, providing a step-by-step guide to performing, reporting, and interpreting a study. We wrote it imagining we were the calm voice of a senior echocardiographer teaching a junior colleague. This edition has been extensively revised with an expansion of sections on acute, intensive care and emergency medicine. COVID-19 has necessitated limiting exposure of both patient and operator to infection and caused a huge increase in waiting lists. This has sharpened the debate over matching the level of scan to the clinical question and also highlights the importance of collaboration between clinicians and echocardiographers.
Key Features
● Expanded first chapter on levels of echocardiography
● New sections on COVID-19, cardio-oncology, multivalve disease, and specialist valve clinics
● Incorporation of new international guidelines, grading criteria, and normal data
● Guide to how cardiac CT and magnetic resonance can complement echocardiography
● Reformatted text and extra diagrams and tables to improve understanding
Echocardiography A Practical Guide for Reporting and Interpretation
Fourth Edition
Camelia Demetrescu BSc, MSc, HSSE
Consultant Clinical Scientist in Cardiology
Guy’s and St Thomas’ Hospitals, London
Sandeep S Hothi MA, PhD, FRCP, FACC, FBSE, FESC
Consultant Cardiologist
Royal Wolverhampton NHS Trust
Honorary Senior Clinical Lecturer University of Birmingham
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DOI: 10.1201/9781003242789
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Preface
This book sets echocardiography within a routine clinical context. It aims to synthesise guidelines into a pragmatic clinical approach to real patients, providing a step-by-step guide to performing, reporting, and interpreting a study. We wrote it imagining we were the calm voice of a senior echocardiographer teaching a junior. We also designed lists and tables as aidesmemoires for the experienced echocardiographer or interpreting physician.
How We Handled Guidelines and Data
We took account of all up-to-date guidance from the ESC and ACC/AHA and also any other national or international body of authority that offered complementary or corroborative data or advice. Where guidelines disagreed or deviated from usual clinical practice, we conducted informal polls of internationally respected colleagues and reported the range of actual clinical practice marked by a logo to note the need for discussion within an individual department. If there were more recent normal ranges based on better collected data from larger populations than quoted in international guidelines, we used these. For example, we used the NORRE data for aortic diameters.
Expansion of Echocardiography
Since the third edition, echocardiography has expanded further into acute, intensive care, and emergency medicine. COVID-19 has necessitated limiting exposure of both patient and operator to infection and also caused a huge increase in waiting lists. This has sharpened the debate over the balance between abbreviated scans and comprehensive studies and highlighted the importance of collaboration between clinicians and echocardiographers. It is clear that the nature of the cardiac scan should be tailored to the clinical question, and this has led to the development of a range from basic, through focused, to standard and comprehensive echocardiograms. We discuss this in an expanded first chapter.
New Sections
We also include new sections on COVID-19, cardio-oncology, multivalve disease, and specialist valve clinics. We incorporated new international guidelines, grading criteria, and normal data. Since the third edition, there has been further development of cardiac CT and magnetic resonance, and we explain where these techniques are complementary to echocardiography and should be incorporated in a multimodality approach to normal clinical practice.
General Changes
The text has been reformatted to be more easily accessible, and numerous diagrams have been added or updated. Images and clips have been placed in a web-based archive.
This book will be relevant to all echocardiographers, including cardiac physiologists, clinical scientists, cardiologists, and clinicians in acute, critical care, general, and emergency medicine. It will also be useful to hospital and community physicians needing to interpret reports.
Acknowledgements
We should like to thank the people who took part in our online straw polls: Brian Campbell, Laura Dobson, Madalina Garbi, Jane Graham, Antoinette Kenny, Navroz Masani, Jim Newton, Petros Nihoyannopoulos, Keith Pearce, Bushra Rana, Dominik Schlosshan, Roxy Senior, Benoy Shah, and Rick Steeds. We are also grateful to colleagues who read through chapters and offered helpful advice: Claire Colebourne, Jane Draper, Yaso Emmanuel, Madalina Garbi, Jane Graham, Jeffrey Khoo, Simon MacDonald, Peter Saville, and David Sprigings. Any remaining mistakes are ours and not theirs. We should also like to thank Phillip Bentley, graphic designer, for updating the diagrams.
Authors
Camelia Demetrescu, BSc, MSc, HSSE, is Consultant Clinical Scientist in Cardiology, with specialist interest in echocardiography, at Guy’s and St Thomas’ Hospital. She has extensive NHS clinical, teaching, research, managerial, and leadership work experience across multiple London NHS tertiary trusts. She has a specialist interest in the management of patients with heart valve disease and interventional cardiology, inherited cardiomyopathies, heart transplant and assist devices, and most recently, in the research and development of AI technology. She is an active member of the European Association of Cardiovascular Imaging, the British Society of Echocardiography, British Heart Valve Society, Academy for Healthcare Science, and the National School of Healthcare Science.
Sandeep S Hothi, MA, PhD, FACC, FBSE, FESC, FRCP, is Consultant Cardiologist and Clinician-Scientist with expertise in advanced cardiac imaging. He studied at the University of Cambridge for undergraduate and postgraduate medical and scientific degrees: 1st Class BA (Hons) degree, clinical medical and surgical degrees (MB BChir) and a research degree (PhD) in cardiac cellular and whole heart physiology. He is a Consultant Cardiologist at New Cross Hospital, Wolverhampton, and Honorary Senior Clinical Lecturer at the University of Birmingham. He is accredited (SCMR, EACVI CMR, BSE, SCCT) in Echocardiography (transthoracic, transoesophageal, stress echo), Cardiac MRI and Cardiac CT. He holds societal roles with the British Society of Echocardiography as elected Trustee and Council Member, lead examiner for TOE accreditation, and Accreditation committee member.
John Chambers, MD, FRCP, FESC, is Emeritus Professor of Clinical Cardiology at Guy’s and St Thomas’ Hospital and KCL and was previously Head of Adult Echocardiography there. He helped in the foundation of the British Society of Echocardiography and was President from 2003 to 2005, responsible for establishing minimum standards for performing and reporting echocardiograms. He also helped set up individual transthoracic, transoesophageal, and departmental accreditation and a training system for basic echocardiography. He ran the London Echo Course for ten years and remains a faculty member of many national teaching courses. He has helped write a number of international documents on the imaging assessment of valve disease, including prosthetic valves. He was a founder-member and the first president of the British Heart Valve Society and helped set standards for specialist valve clinics and heart valve centres. He has written ten books on echocardiography, heart valve disease, and general medicine. He was awarded the British Cardiovascular Society 2023 Mackenzie medal for his career-long work in echocardiography and heart valve disease.
Disclaimer
The information in this book is based on a synthesis of data and guidelines available at the time of printing. The reader should be aware that clinical interpretation may change, and the writers cannot be held responsible for clinical events associated with the use of this book.
Icons and QR Codes
A number of new icons and QR codes have been used in this edition of the book to increase its usefulness to practitioners.
Throughout the book, the CHECKLIST icon is used to signal checklist boxes summarising the main information on topics discussed.
The ALERT icon flags up points to be particularly aware of or mistakes to avoid.
The THINK icon marks a point of controversy or where consensus has not been reached.
A point requiring discussion in an individual patient with integration into the clinical context is indicated by the DISCUSSION icon.
Abbreviations
AF atrial fibrillation
Ao aorta
ARVC/D arrhythmogenic right ventricular cardiomyopathy/dysplasia
AR aortic regurgitation
AS aortic stenosis
ASD atrial septal defect
AVSD atrioventricular septal defect
BSA body surface area
CABG coronary artery bypass graft
CMR cardiovascular magnetic resonance
CSA cross-sectional area
CT computerised tomography
CW continuous wave
DCM dilated cardiomyopathy
dP/dt rate of developing pressure
ECG electrocardiogram
ECMO extracorporeal membranous oxygenation
EF ejection fraction
EOA effective orifice area
EROA effective regurgitant orifice area
FDG fluorodeoxyglucose
HCM hypertrophic cardiomyopathy
IVC inferior vena cava
IVS interventricular septum
LA left atrium/left atrial
LAA left atrial appendage
LBBB left bundle branch block
LMS left main stem
LV left ventricle/ventricular
LVDD LV end-diastolic diameter
LVEDV LV end-diastolic volume
LVEDVi LV end-diastolic volume indexed to BSA
LVESV LV end-systolic volume
LVESVi LV end-systolic volume indexed to BSA
LVEDP LV end-diastolic pressure
LVOT LV outflow tract
LVSD LV end-systolic diameter
MOA mitral orifice area
MR mitral regurgitation
MS mitral stenosis
PA pulmonary artery
PCI percutaneous coronary intervention
PDA persistent ductus arteriosus
PEEP positive end-expiratory pressure
PET positron emission tomography
PFO patent fossa ovalis
PH pulmonary hypertension
PISA proximal isovelocity surface area
PR pulmonary regurgitation
PS pulmonary stenosis
RA right atrium/atrial
RF regurgitant fraction
RV right ventricle/ventricular
RVOT right ventricular outflow tract
Abbreviations
RVEDV RV end-diastolic volume
RVESV RV end-systolic volume
RWT relative wall thickness
STJ sinotubular junction
SV stroke volume
SVC superior vena cava
TAPSE tricuspid annulus peak systolic excursion
TAVI transcatheter aortic valve implantation
TDI tissue Doppler imaging
TOE transoesophageal echocardiogram/ echocardiography
VTI velocity time integral (VTIaortic measured on continuous wave Doppler through the aortic valve, VTImitral measured on continuous wave Doppler across the mitral valve, and VTIsubaortic measured on pulsed Doppler in the LV outflow tract)
Defining the Study
1
Deciding the Level of Echocardiogram Required
● Cardiac ultrasound has now expanded in:
● Setting—from the echocardiography laboratory to include cardiac and general wards; GP surgery and community echo clinics; the interventional laboratory, theatre, and intensive therapy unit; the emergency room and emergency settings, e.g. the road side or battlefield.
● Application—from cardiology to acute, emergency, and intensive care medicine; to exclude significant structural disease in the community or the outpatient clinic.
● Hardware—from high-end system through mid-range portable machines to handheld devices.
● Training—from the use of cardiac ultrasound as an aid to resuscitation (by first responders) to basic studies (by the accredited physician in charge of the case or by accredited and highly experienced echocardiographers), to focused echocardiograms e.g. for community screening projects (often by nurses), to standard echocardiograms (by accredited echocardiographers), and to comprehensive studies (accredited and highly experienced echocardiographers).
● Cardiac ultrasound (e.g. FATE or FEEL protocols), usually including chest and abdominal imaging, is separate from echocardiography and part of emergency management.
● There are four levels of transthoracic echocardiography (TTE) (Table 1.1).
● Deciding the level of scan requires collaboration between clinician and echocardiographer (Figure 1.1) via:
● A system of formal triage, including cases which do not need an echocardiogram at all (e.g. repeat studies with no clinical change).
● Discussion about individual cases (e.g. in valve or heart failure specialist clinics).
● The decision on the level of scan will be based on:
● The likelihood of disease. A basic TTE is sufficient to confirm the clinical impression of normality in low-risk cases, for example, flow murmurs or perceived palpitation in a young person1, 2. By comparison,
DOI: 10.1201/9781003242789-1
Table 1.1 Aims of the four levels of echocardiogram (TTE) (Figure 1.1)
Basic scan—can be performed with a handheld device with colour by an accredited* and highly experienced echocardiographer.**
● To detect pathology requiring immediate correction in the emergency setting (often performed by the physician in charge of the case).
● To determine what further investigations are indicated.
● To exclude the need for a minimum standard study in a patient at low clinical risk of disease.
Focused study—typically performed using a mid-range machine by an accredited echocardiographer* or operator specifically trained for a community screening project.
● To identify specific abnormalities in screening projects, for example, LV systolic and diastolic dysfunction, heart valve disease3, 4 .
● To detect change, for example, after an intervention in ITU, a new pericardial effusion after a cardiac intervention, an improvement in LV function after heart failure therapy, or in LV function on serial cardiooncology scans.
● To detect significant change requiring a comprehensive study in patients with previous minimum standard studies, for example, moderate valve disease in a specialist valve clinic.
Minimum standard study—performed with at least a mid-range machine by an accredited echocardiographer,* if necessary, under supervision.
● This is the set of views and measurements (Tables 1.2 and 1.3) without which a study cannot be relied on to exclude significant pathology.
Comprehensive study—performed using a high-end machine by an accredited* and highly experienced echocardiographer.**
● This is a minimum standard study with additional disease-specific measurements (Table 1.4) as described in the chapters in this book.
* Accredited by a recognised national board or system, for example, the British Society of Echocardiography, European Association of Cardiovascular Imaging, American Society of Echocardiography, Australian BSc.
** Highly experienced echocardiographers are expected to notice mild abnormalities requiring a more extended study more readily than junior echocardiographers do.
a comprehensive study is more appropriate for a patient with a family history of cardiomyopathy.
● The results of previous studies. Confirming the stability of a previously noted abnormality does not usually need a comprehensive TTE.
● The clinical question. This might range from detecting signs of subtle disease (needing a comprehensive study) to whether the LV ejection fraction has changed (suitable for a focused study).
● Team working means that studies can be extended if unexpected pathology is detected.
The Basic Scan
● This is effectively an extension of the clinical examination and has these features4–6:
● Basic views, usually: (1) parasternal long- and (2) short-axis (scanning from papillary muscles to aorta); (3) apical 4- then tilting to 5-chamber; (4) subcostal (Figure 1.2).
● Systematic assessment of key cardiac structures: (1) LV size and function; (2) RV size and function and IVC; (3) valves; (4) presence of pericardial fluid.
● Includes colour Doppler to detect significant valve disease.
● The result is classified as:
● Major abnormality requiring immediate action, for example, pericardial tamponade, RV dilatation (as a surrogate for massive pulmonary embolism)7
● Normal.
● Requiring higher-level TTE (which can often be done immediately if equipment and operator appropriate), for example, more than trivial abnormalities, or basic scan apparently normal but patient unwell.
Figure 1.1 Choosing the level of echocardiogram.
Figure 1.2 A template showing views for the basic echocardiogram.
● A suggested aide-memoire is given in Figure 1.2, but individual laboratories may add extra views or measurements as routine, for example, apical 2-chamber view or measurement of LV septal thickness or TR Vmax if tricuspid regurgitation is detected or LA diameter in an electrophysiology request.
The Focused Study
● This always starts with a basic scan, to which specific ‘add-ons’ are determined by a clinical or research protocol or as directed by the clinician in charge of the case8
● Examples of ‘add-ons’ are:
● TR Vmax if more than mild TR shown9
● RV tissue Doppler S′ velocity, TAPSE, and TR Vmax in sickle cell disease, in SLE, or in pulmonary embolism before and after thrombolysis.
● Aortic dimensions and aortic regurgitation in a patient in an aortopathy clinic.
● LV measurements to estimate LV mass in hypertension10.
● LV systolic function alone9 or IVC reactivity11 in follow-up heart failure clinics.
The Minimum Standard Study
● A minimum dataset of views and measurements is required to:
● Confirm normal cardiac structure and function (Tables 1.2 and 1.3).
● Reduce the risk of missing significant abnormalities.
● Minimise inter- and intra-observer variability and enable accurate comparison of serial TTE.
● Provide a structure for departmental quality audit.
● Clinically important measurements should be included in the text of the report.
● Confining all measurements to a computer-generated section encourages their proliferation. Clinically important measurements may not be noticed especially if the requestor is a non-echocardiographer.
● Each department should decide how many measurements to make and which should be brought into the text.
● Some protocols suggested by professional societies for a minimum standard study include measurements more properly classified as comprehensive.
● Each department needs to discuss how to manage measurements in atrial fibrillation.
● Most aim to obtain measurements on cycles with instantaneous heart rates close to 60–70 bpm.
● Once critical disease has been excluded by a basic TTE, it may be appropriate to bring the patient back once rate-controlled to continue the minimum standard study.
Table 1.2 Minimum standard adult transthoracic echocardiogram (TTE) protocol12–15
View
P/S long axis
P/S RV inflow
P/S RV outflow
P/S short axis at AV
2D, colour Doppler
2D, colour Doppler
CW of TV if TR found
2D, colour Doppler
2D, zoom, colour Doppler
PW in RV outflow
CW of PV and main PA
CW of PR
CW of TV if TR found
(Continued)
Table 1.2 Minimum standard adult transthoracic echocardiogram (TTE) protocol (Continued)
View
P/S short axis at MV
P/S short axis at pap muscles
P/S short axis at apex
Apical 4 chamber
RV/RA modified Apical 4 chamber
Apical 5 chamber
Apical 2 chamber
Apical long axis
Subcostal long axis
Subcostal short axis
Subcostal abdominal aorta
Suprasternal notch–aortic arch
* To exclude a VSD.
Essential imaging modalities**
2D, colour Doppler*
2D, colour Doppler*
2D, colour Doppler*
2D, colour Doppler
PW of MV
CW of TV if TR found
Doppler tissue MV and TV annulus
2D, colour Doppler of TV
M-mode TAPSE ± tissue Doppler
CW of TV if TR found
2D, colour Doppler
PW of LVOT
CW of AV
2D, colour Doppler
2D, colour Doppler
2D, zoom on IVC and IAS, colour
Doppler (IAS; hep vein)
IVC reactivity by eye
2D, colour Doppler
2D, colour Doppler
2D, colour Doppler
** Extra views are suggested by some guidelines12–15, e.g. CW of valves even if imaging and colour normal, LV strain.
Table 1.3 Minimum measurements for standard adult TTE protocol
Left ventricle
Diameters 2D: LVDD; LVSD; IVSd; PWd
2D volumes or 3D (when available)—BSA indexed*: LVEDVi and LVESVi
EF (using 2D or 3D volumes); VTIsubaortic
Mitral E/A and E/E’ ratio using E’ at septum ± lateral ± averaged according to local protocols
Left atrium
2D Volume (biplane method) or 3D—BSA indexed
Right ventricle
RV basal diameter; TAPSE and/or S’ on tissue Doppler
TR Vmax; acceleration time of PW in RV outflow tract
Inferior vena cava (inspiratory change): RA pressure assessment
Right atrium
2D area—2D Volume or 3D (when available)—BSA indexed
Aorta
2D diameter at sinuses, sinotubular junction, and ascending aorta indexed to height if at extremes of height
Aortic valve
CW Vmax
* If BMI > 30 Kg/m2, do not index to BSA, which underestimates the degree of cardiac remodelling.
The Comprehensive Study
● This is a minimum standard study plus extra views and measurements depending on the clinical question or known pathology (Table 1.4).
Table 1.4 Views and measurements or descriptions as add-ons to the minimum standard according to the indication for the study
Indication Views
Possible LV dysfunction (indication heart failure, cardiomyopathy)
Possible RV dysfunction
Aortic stenosis
● Zoom LVOT and MV in HCM
● Zoom LV apex +/– colour Doppler in cardiomyopathy or myocardial infarction
● Modified LV views in suspected post-infarct VSD
● Contrast study for endocardial border delineation/thrombus
● RV-specific views (page 35)
● Zoom RV apex
● M-mode of annulus in zoomed 4-chamber view
● Zoom in LVOT
● CW at apex and RICS
Measurements/ observation
● RWT and LV mass BSA indexed (g/m2)
● 2D/3D dyssynchrony parameters
● 3D volume and ejection fraction
● GLS
● LVOT obstruction at rest/Valsalva in HCM
● RV 2D P/S long- and short-axis diameters
● RV fractional area change
● RV EF on 3D
● LVOT diameter
● Vmax, mean ∆P, EOA
● CW to exclude coarctation
● Evidence of PHT (Continued)
Table 1.4 Views and measurements or descriptions as add-ons to the minimum standard according to the indication for the study (Continued)
Indication
Aortic regurgitation
Views
● Zoom aortic root and ascending aorta
● AR CW
● Colour M-mode suprasternal
Mitral regurgitation
● Zoom MV in all views
● PW in pulmonary vein
Measurements/ observation
● Colour jet width
● AR pressure half-time
● Flow reversal in descending aorta (PW and colour)
● Detailed valve morphology and mechanism of MR
● MV annulus size
● Tenting height/area
● PISA/vena contracta
● Evidence of PHT
Mitral stenosis
● Zoom MV in all views
Pericardial constriction
● PW at MV (slow sweep speed)
● PW in hepatic veins
● MV annulus tissue Doppler
Organisation of a Report
● MV orifice planimetered area
● Vmax, pressure 1/2 time (and estimated area), mean gradient
● Evidence of PHT
● Look for septal bounce
● Resp variability in transmitral PW
● Septal and lateral tissue Doppler E’
1. The minimum standard report16 should include:
● Basic data:
● Patient name, date of birth, and hospital number.
● Echocardiographer ID (initials/name).
● Information regarding echocardiographic machine, type of image storage media, and location is recommended to facilitate review.
● Minimum patient observations:
● Age and sex and body dimensions (height, weight, body surface area).
● A good-quality ECG trace for heart rate and rhythm.
● Indication. A TTE should not usually be performed without a written request (except in life-threatening emergencies). The request should include:
● The indication (ideally including previous medical history).
● Clinical questions to be answered.
● Referrer details (name, title, address, email).
● Minimum measurements (see Table 1.3). Clinically important measurements need to be given in the text of the report, and it is not sufficient to have these in a list of machine-generated numbers.
● The main text should include:
● A description of image quality (poor, adequate, good).
● A description of the morphological and functional findings of all parts of the heart and great vessels.
● If it was not possible to image a region, this should be stated.
● Preliminary interpretation can be included where it aids understanding, for example, ‘rheumatic mitral valve’. The grade of stenosis or regurgitation can also be stated as long as the observations used are included.
● No consensus exists about reporting minor abnormalities (e.g. mild mitral annulus calcification), normal variants (e.g. Chiari network), or normal findings (e.g. trivial mitral regurgitation). We suggest describing these in the text but omitting them from the conclusion.
● The summary:
● Must answer the clinical question posed by the referrer.
● Must emphasise abnormal findings in descending order of clinical importance.
● Should identify the abnormality (e.g. mitral regurgitation), its cause (e.g. mitral prolapse), and the secondary effects (e.g. LV dilatation and hyperactivity).
● Should compare with previous findings if available.
● Should avoid abbreviations and be understood by non-specialist healthcare professionals.
● Should not usually include clinical advice. This requires the echocardiographic findings to be integrated with the broader clinical assessment, which is not available to the echocardiographer. However, it may be reasonable to offer implicit management advice in the report, for example: 1) ‘Valve suitable for balloon valvotomy based on echocardiographic assessment.’; 2) ‘Valve suitable for repair based on echocardiographic assessment.’; 3) ‘Severe mitral regurgitation with LV dilatation at thresholds suitable for surgery.’
Escalation for Urgent Clinical Advice
● Each laboratory should have a system of identifying critical findings (Table 1.5) and communicating them to the referrer or a cardiologist.
● Documentation of communication of the critical findings must be recorded in the report and/or in the patient’s medical record.
Table 1.5 Examples of critical findings requiring urgent clinical advice
Critically unwell patient, regardless of echocardiographic findings
Pericardial effusion: large or with evidence of tamponade
Aortic dissection or grossly dilated ascending aorta or abscess
Previously undiagnosed severely impaired LV systolic function
Serious complications of an acute coronary syndrome:
● Ventricular septal rupture
● Papillary muscle rupture
● False aneurysm
RV dilatation or hypokinesis in a patient with suspected pulmonary embolism
New severe valve disease
New cardiac mass or thrombus
Understanding the Report for Non-Echocardiographers
1. Some findings are almost never of clinical importance:
● Mild tricuspid and pulmonary regurgitation, which are both normal findings. Isolated moderate tricuspid regurgitation is also within normal limits if the RV is not dilated and the left heart is normal.
● Mild mitral regurgitation with a normal valve appearance and normal LV size and function.
● ‘Sigmoid septum’ (or ‘septal bulge’), which is common in the elderly and may cause a murmur.
● Trivial pericardial fluid especially localised around the right atrium (in the absence of chest pain, suggesting pericarditis).
● An incidental patent foramen ovale in the absence of a relevant clinical history (TIA or stroke, peripheral embolism, diving).
2. What do class 1, 2, and 3 diastolic dysfunction mean?
● Echocardiographers are now encouraged to describe the pattern of LV filling using a system of classification. ‘Slow filling’, which is common and arguably normal in the elderly, has become ‘class 1 diastolic dysfunction’.
● Class 2 and 3 dysfunctions suggest high LV filling pressures, but these classes are easily confused with diastolic heart failure, which is a clinical diagnosis that cannot be made on TTE alone.
● If the patient is well, it is likely that LV diastolic dysfunction is an incidental observation of no clinical significance.
3. How do I interpret a probability of pulmonary hypertension?
● If the request was to detect pulmonary hypertension (e.g. in the context of SLE), then the recommendation is to report a low, intermediate, or high probability of pulmonary hypertension (see Chapter 5). TTE cannot estimate PA pressure reliably enough to make a management-changing diagnosis. Further investigation potentially with a right heart catheter is then needed.
● If the patient has valve disease:
● In mitral stenosis, a PA systolic pressure >50 mmHg at rest is an indication for balloon valvotomy even in the absence of symptoms.
● In severe aortic stenosis (AS), a PA systolic pressure >60 mmHg indicates a high risk of dying, unless surgery or a TAVI is performed.
● A rise in TR Vmax is a secondary sign of deterioration in any type of valve disease.
● If the request was for any other reason and no other cardiac abnormalities are reported, seek a cardiac opinion.
4. In specific diseases, there are echocardiographic findings that might trigger changes in management (Table 1.6)
Table 1.6 Alerts in the echo report by pathology
Asymptomatic severe valve disease. Check that LV size and function are normal
In severe mitral regurgitation, surgery may be indicated for a systolic diameter >40 mm or LV ejection fraction approaching 60% (see Chapter 9).
In severe aortic regurgitation, surgery may be indicated for a systolic diameter >50 mm, diastolic diameter >65 mm, or LV ejection fraction approaching 50% (see Chapter 8).
Moderate disease may still be significant if the LV size and function are abnormal.
